Improving Access and Quality
Use of Dental Crowns and Alternatives Varies
Another AHRQ-funded study looked at the use of dental
crowns and their alternatives.16 It found that the use of
crowns among patients with substantially compromised
posterior teeth varies significantly by age and region and
that these differences, in turn, are related to substantial
differences in costs. The study found that older patients are
significantly more likely to receive crowns than young
patients. Patients 50 and over had an average cost per tooth
of $269, compared to an average cost per tooth of $181 for
patients ages 18-34. Also, regional variation in the
provision of crowns appears to contribute to a 31-percent
difference in the average per-tooth treatment cost between
the highest and lowest cost regions. The most notable
geographic difference in average cost per tooth was
between the Northeast ($173) and the West ($251). Based
on the sample included in the study, the average cost of
restoring a tooth requiring either a crown or its alternative
was $225. Since crowns can cost up to six times as much
as the alternative, seemingly small differences in the use of
crowns can have major effects on overall costs.16
In addition, the ratio of crowns to their alternatives varies
more than the amount that can be accounted for by the
patient and practice factors that were measurable through
the claims data used in this study, raising questions about
the consistency of dentists' treatment recommendations.17
For example, 43 percent of practices provided crowns at
either 50 percent below or 150 percent above the expected
rate. This variation found at the practice level also raises
concerns about the appropriateness of care. However, as the
researchers note, "...a determination of appropriateness
depends upon comparison with a known standard of
treatment effectiveness, which is currently unavailable."15
Other reasons for disagreement about treatment
recommendations could include differences in the
thoroughness of the examination, application of diagnostic
criteria used to define a condition, assessment of risk,
interpretation of nonclinical patient factors, and
interpersonal interaction between the dentist and patient.
The researchers concluded that if a substantial portion of
the variation noted in this study indeed stems from dentists'
idiosyncratic use of crowns, the profession has a clear
indication of the need to improve knowledge of treatment
outcomes among practitioners. Since there is substantial
disagreement about the relative life expectancies of crowns
vs. their alternatives, the researchers conclude that more
outcomes effectiveness research is needed, given the wide
difference in the costs of alternative treatments.
In fact, one of the researchers points out that the dental
profession lacks basic evidence that many of the dental
treatments provided are even effective.17 He also suggests
that soon payers and consumers will no longer accept
anecdotal stories about quality; they will want measurement
and quantification instead. He argues that dental schools
are the logical site for the development of valid, reliable,
and acceptable health services research methods and
databases. In addition, he describes the actual development
of an insurance claims database to demonstrate the types of
investigations possible with it. This database was used to
conduct the study described here on practice variations in
the use of crowns.16
Dental Performance Measures Have Been Developed
Performance measures for dental care plans can improve
the ability to measure effectiveness of care and use of
services, but no standardized measures of the performance
of dental care plans exist. Currently most plans do not
collect sufficient administrative information to determine
the outcomes of care delivered by their providers. To fill the
gap left by the lack of standardized performance measures,
AHRQ-funded researchers developed seven effectiveness-of-care measures and six use-of-services measures modeled
after the Health Plan Employer Data and Information Set
(HEDIS®) measures of medical care.18
Effectiveness-of-Care Measures
- Current disease activity assessment.
- Preventive treatment for caries-active children and adults.
- New caries.
- Periodontal treatment for perio-present adults.
- Improvement in periodontal status.
- Deterioration in periodontal status.
- Tooth loss.
Use-of-Services Measures
- Receipt of prophylaxis.
- Preventive treatment: restorative treatment ratio.
- Casting (e.g., crown, inlay): large direct fillings ratio.
- Endodontic treatment: extraction ratio.
- Receipt of third molar (wisdom tooth) extractions.
- Mean number of third molars extracted.
Source: Bader JD, Shugars DA, White A, et al. Development of effectiveness of care and use of services measures for dental care plans. J Public Health Dent 1999;59(3):142-9.
|
The measures enable oral health plans to determine the
percentage of enrollees with various conditions and the
percentage receiving various services. Since basic
restorative and periodontal care accounts for one-half of all
dental expenditures and approximately 50 percent of the
population has some dental care coverage, these measures
cover care costing more than $10 billion.
All of the measures are expressed as proportions, i.e., the
proportion of all enrollees meeting certain criteria who have
experienced a certain clinical outcome or have received a
certain service. For example, the first effectiveness-of-care
measure, "current disease activity assessment," reports the
percentage of all enrollees who have had a caries activity
assessment within 2 years of the end of the reporting year.
The proportions for children (ages 6-17) and adults (ages
18 and over) are reported separately. The second and third
measures address dental caries: a process measure assessing
receipt of appropriate preventive services such as fluoride
treatment or dental sealants, and an outcome measure
assessing caries experience among enrollees. This pattern is
repeated for periodontal disease. A final measure assesses
the extent of tooth loss from both diseases.
Of the six use-of-services measures, three are ratio
measures comparing the provision of services that could be
considered alternative therapies (e.g., endodontic treatment
vs. extraction). Two measures are concerned with wisdom
tooth (third molar) extractions. Another measure is a
traditional assessment of the proportion of enrollees
receiving prophylaxis.
The two groups of measures were pilot tested using
administrative data from two group model oral health plans
with approximately 205,000 eligible enrollees. The testing
provided partial evidence that the measures are reliable and
sensitive to differences among plans. However, the results
reported in the study are not to be taken as benchmarks for
comparison with other dental plans since they are the first
such performance data to be reported for any dental plan.
The measures offer several advantages that can help
promote their implementation. They can be calculated
directly from a dental plan's administrative data system
(assuming that the system included diagnostic codes),
thereby minimizing data collection costs and related
recording errors. They are standardized to facilitate
comparisons across plans. They include a means of risk
adjustment to account for differing oral disease status
among enrollees of different plans. However, the measures,
in their final form, cannot be widely implemented
immediately because diagnostic codes are not routinely
used in dentistry and a universally accepted set of codes is
not available at present. The researchers also reported a set
of interim measures that can be applied using audit-based
data until carriers do include diagnostic codes in their
administrative data systems.19
Scientific Evidence for Tooth Decay Treatment
Strategies Is Limited
Measuring the quality of care presupposes the ability to systematically evaluate
the validity and effectiveness of diagnostic, preventive, and surgical interventions.
AHRQ, in a collaborative effort with the National Institute of Dental and Craniofacial
Research (NIDCR), sponsored an evidence report systematically evaluating research
on the diagnosis, prevention, and nonsurgical treatment of dental caries.20
The Evidence-based Practice Center (EPC) performing the analysis looked at 39
studies describing the performance of diagnostic methods.f
The analysis included separate evaluations for different types of tooth decay
(e.g., cavitated lesions, lesions involving dentin, enamel lesions) and also
for different surfaces and tooth types.
The EPC
report found that that the strength of the evidence on the
performance of almost all diagnostic methods is poor.
Several factors were responsible:
- An insufficient number of studies.
- Variation among reported results.
- The quality of the available studies.
The evidence did not support the
superiority of either visual or visual/tactile diagnostic
methods since the number of available assessments was
small and there was substantial variation among the reports
for each method. The evidence suggests, but is not
conclusive, that some digital radiographic methods offer
small gains in sensitivity compared to conventional film x-rays.
The evidence also suggests that electrical
conductance methods may offer heightened sensitivity on
occlusal surfaces, but at the expense of specificity. Again,
the evidence was not conclusive.
The EPC also reviewed nine methods of managing caries-active
individuals: fluoride varnishes, fluoride topical
solutions, fluoride rinses, chlorhexidine varnishes,
chlorhexidine topicals, chlorhexidine rinses, combined
chlorhexidine-fluoride applications, sealants, and other
approaches. In its analysis of 35 studies, the evidence for
the efficacy of fluoride varnishes was rated as fair and the
evidence for all other methods was incomplete.g
Once again, the number of available studies for any specific method proved
to be a serious limitation. Among studies addressing a method, the variety of
experimental protocols, comparison groups, and other community and individual
preventive dentistry exposures further restricted the opportunity to draw conclusions
about the efficacy of specific methods. Also, generalization from the studies
to the broader U.S. population is problematic, as nearly all studies included
only children and evaluated changes only in the permanent teeth.
Finally, the EPC report evaluated the the efficacy of
preventive methods among individuals who have
experienced, or are expected to experience, an elevated
incidence of noncavitated tooth decay. Here the evidence
was rated as incomplete, since the team found only five
studies addressing the topic. No conclusions were drawn.
f. Evidence reports are based on rigorous, comprehensive reviews of
relevant scientific literature performed under contract by Evidence-based
Practice Centers. The reports' emphasis is on explicit and detailed
documentation of methods, rationale, and assumptions. The goal of these
reports is to provide the scientific foundation that public and private
organizations can use to develop their own clinical practice guidelines,
quality measures, review criteria, and other tools to improve the quality
and delivery of health care services.
g. The conclusions of the EPC report apply to research published between
1966 and 1999. The earlier discussion of sealant effectiveness was based
on research published in 2001.
More AHRQ-Funded Evidence Reports on Dental Care
Are Available
Cardiovascular Effects of Epinephrine in Hypertensive
Dental Patients
AHRQ and NIDCR sponsored and issued
an evidence report on the cardiovascular effects of
epinephrine in hypertensive dental patients.21 Epinephrine
is widely used as an additive in local anesthetics to improve
the depth and duration of the anesthesia, as well as to
reduce bleeding. The added risks attributed to the use of
epinephrine in hypertensive patients include the increased
probability of acute hypertensive crisis (dangerously high
blood pressure), angina pectoris, myocardial infarction, and
cardiac arrhythmias.
The EPC looked at five studies on the outcomes of the use
of epinephrine-containing anesthetic solutions in
hypertensive patients. The report rated the evidence on this
issue as poor because the outcomes considered in the five
studies did not represent a reasonably complete assessment
of risk indicators. Also, transient effects in blood pressure
and heart rate, the principal outcomes reported, might have
remained undetected in three of five studies.
The EPC recommended that a long-term research study be
initiated in one or more large dental clinics in order to
quantify the magnitude of additional risk represented by the
use of epinephrine in hypertensive dental patients.
Management of Dental Patients Who Are HIV Positive
Another evidence report cosponsored by AHRQ and
NIDCR focused on several aspects of the dental
management of a special population subgroup—the
estimated 900,000 people in the United States with
HIV/AIDS.22 These aspects include:
- Complications associated with invasive dental
treatments.
- Dental conditions as markers or indicators of change in
HIV serostatus and immunosuppression.
- The efficacy or effectiveness of available antifungal
drugs to prevent or treat oral candidiasis.
The EPC found that there is limited evidence on the risks of
oral procedures among people with HIV/AIDS. Very few
studies have been reported, and only two types of
procedures—root canal therapy and extractions—have been
investigated. From this limited base, there is little evidence
of unusual rates or severity of complications for these
procedures among people with HIV/AIDS.
Evidence for the utility of selected oral lesions as markers
for seroconversion is limited to a single study of a single
oral condition—candidiasis. The review does not suggest
the use of oral conditions as markers for seroconversion.
The evidence with respect to the efficacy of fluconazole to
prevent oropharyngeal candidiasis is good, but for other
antifungal agents there is no evidence. The situation is
different with respect to the effectiveness of antifungals as
treatments for oropharyngeal candidiasis. With the
exception of amphotericin B, the evidence is good that all
tested antifungals are effective, although all are not equally
effective.
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Ongoing Research and Programs
U. S. Preventive Services Task Force (USPSTF)
Recommendations on Dental Care. In fall 2003, the
USPSTF will issue recommendations to cover primary
prevention in pre-school-aged children. These
recommendations will update the previous USPSTF
recommendations, which were issued in 1996.
The Effect of Public Insurance on Oral Health
Outcomes. University of North Carolina. R03 HS11514.
This project represents an in-depth comparison of the use of
dental services, effectiveness of established pediatric oral
health performance measures, and oral health status for
children enrolled in either the North Carolina Medicaid
program or the North Carolina Health Choice for Children
program (North Carolina's SCHIP program). This study
provides an opportunity to determine the benefits of public
dental insurance for low-income children when it is
structured similarly to private insurance.
Effects of WIC on Child Medicaid Dental Use and
Costs. University of North Carolina. R03 HS11607. The
purpose of this research project is to examine the
relationship of the Women, Infants and Children's
Supplemental Food Program (WIC) on the oral health use
patterns and cost to the Medicaid program of children
under age 5. The current low level of oral health service use
in Medicaid had presented a major public policy challenge,
as evidenced by reports from the Office of Technology
Assessment, the General Accounting Office, and the Office
of the Surgeon General. This investigation will examine the
role of a partnership between Medicaid and WIC, and its
effects on Medicaid use and expenses.
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Conclusion
Despite a falling general rate of tooth decay among
children, widespread disparities exist in the provision of
care to poor and minority populations because of a cluster
of access and financial issues. Availability of coverage and
provider reimbursement rates seem to make a difference in
access to care and in quality of care.
Measuring the quality of dental care provided through
dental care plans is a difficult task, but one that has
parallels in performance measures already in use for health
care. The quality of dental care provided by oral health
plans could benefit if performance measures developed for
dental services by AHRQ-funded research were put into
broader use. AHRQ's evidence reports, such as the one on
validity and efficacy of diagnostic, treatment, and
preventive strategies for carious lesions, are designed to
evaluate the strengths and weaknesses of existing research
on a broad array of health care subjects. Where gaps in the
research are shown to exist, AHRQ-funded research, such
as evaluation of the effectiveness of dental sealants, can
help to address the need for more evidence-based practice.
In addition, the relatively recent growth in alternative
treatments available for both diagnosis and management of
dental caries has yet to be fully assimilated by dental practice. Thorough reviews of methods for diagnosis and
management of dental caries should assist in that
assimilation process.
AHRQ's research has continued to point out the disparities
in the provision of care that need to be addressed, the
possibility of systematic measurement of dental plan
performance leading to improvements in the quality of
care, and the paths that dental research should take in
pursuing the goal of evidence-based practice.
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AHRQ-Funded Research
The research programs discussed in this report are:
- Clinical Performance Measures for Dental Plans, University of North Carolina School of Dentistry. The project developed
measures of performance for dental care plans. The dimensions of performance for which measures were developed include
the effectiveness of the care provided by the plan (the extent to which appropriate evaluation and treatment is provided and
new disease is prevented), use of services (the rates and/or ratios at which selected services are provided), and access (the
availability of plan benefits to enrollees).
- Strategies for Management of Dental Caries in Children, University of North Carolina School of Dentistry. This project used
North Carolina Medicaid data to explore factors associated with providers' use of sealants in this population, including the
initiation of a reimbursement benefit for dental sealants.
- The Effect of Medicaid Policy on Dentist Participation, Sheps Center for Health Services Research, University of North
Carolina. This project studied how changes in Medicaid policy, in particular fee increases and the size of the Medicaid
population, affect providers' participation in the North Carolina Medicaid program. In addition, the study explored the
relationship between Medicaid price increases and charges to non-Medicaid dental patients.
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References
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AHRQ Publication No. 03-0040
Current as of July 2003
Internet Citation:
Dental Care: Improving Access and Quality. Research in Action, Issue 13. AHRQ Publication No. 03-0040, July 2003. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/dentalcare/dentria.htm